3.5 Crisis and Crisis Intervention

If you were asked to describe someone in crisis, what would come to your mind? Many of us might draw on traditional images of someone anxiously wringing their hands, pacing the halls, having a verbal outburst, or acting erratically. Health care professionals should be aware that crisis can be reflected in these types of behaviors, but it can also be demonstrated in various verbal and nonverbal signs. There are many potential causes of crisis, and there are four phases an individual progresses through to crisis. Nurses and other health care professionals are often the frontline care providers when an individual faces a crisis, so it is important to recognize signs of crisis, know what to assess, intervene appropriately, and evaluate crisis resolution.

Definition of Crisis

A crisis can be broadly defined as the inability to cope or adapt to a stressor. Historically, the first examination of crisis and development of formal crisis intervention models occurred among psychologists in the 1960s and 1970s. Although definitions of crisis have evolved, there are central tenets related to an individual’s stress management.

Consider the historical context of crisis as first formally defined in the literature by Gerald Caplan. Crisis was defined as a situation that produces psychological disequilibrium in an individual and constitutes an important problem in which they can’t escape or solve with their customary problem-solving resources.^[1] This definition emphasized the imbalance created by situation stressors.

Albert Roberts updated the concept of crisis management in more recent years to include a reflection on the level of an individual’s dysfunction. He defined crisis as an acute disruption of psychological homeostasis in which one’s usual coping mechanisms fail with evidence of distress and functional impairment.^[2] A person’s subjective reaction to a stressful life experience compromises their ability (or inability) to cope or function.

Causes of Crisis

A crisis can emerge for individuals due to a variety of events. It is also important to note that events may be managed differently by different individuals. For example, a stressful stimulus occurring for Patient A may not induce the same crisis response as it does for Patient B. Therefore, nurses must remain vigilant and carefully monitor each patient for signs of emerging crisis.

A crisis commonly occurs when individuals experience some sort of significant life event. These events may be unanticipated, but that is not always the case. An example of anticipated life events that may cause a crisis include the birth of a baby. For example, the birth (although expected) can result in a crisis for some individuals as they struggle to cope with and adapt to this major life change. Predictable, routine schedules from before the child was born are often completely upended. Priorities shift to an unyielding focus on the needs of the new baby. Although many individuals welcome this change and cope effectively with the associated life changes, it can induce crises in those who are unprepared for such a change.

Crisis situations are more commonly associated with unexpected life events. Individuals who experience a newly diagnosed critical or life-altering illness are at risk for experiencing a crisis. For example, a client experiencing a life-threatening myocardial infarction or receiving a new diagnosis of cancer may experience a crisis. Additionally, the crisis may be experienced by family and loved ones of the patient as well. Nurses should be aware that crisis intervention and the need for additional support may occur in these types of situations and often extend beyond the needs of the individual patient.

Other events that may result in crisis development include stressors such as the loss of a job, loss of one’s home, divorce, or death of a loved one. It is important to be aware that clustering of multiple events can also cause stress to build sequentially so that individuals can no longer successfully manage and adapt, resulting in crisis.

Categories of Crises

Due to a variety of stimuli that can cause the emergence of a crisis, crises can be categorized to help nurses and health care providers understand the crisis experience and the resources that may be most beneficial for assisting the client and their family members. Crises can be characterized into one of three categories: maturational, situational, or social crisis. Table 3.5a explains characteristics of the different categories of crises and provides examples of stressors associated with that category.

Table 3.5a Categories of Crises

Phases of Crisis

The process of crisis development can be described as four distinct phases. The phases progress from initial exposure to the stressor, to tension escalation, to an eventual breaking point. These phases reflect a sequential progression in which resource utilization and intervention are critical for assisting a client in crisis. Table 3.5b describes the various phases of crisis, their defining characteristics, and associated signs and symptoms that individuals may experience as they progress through each phase.

Table 3.5b Crisis Phases^[3],[4]

Crisis Assessment

Nurses must be aware of the potential impact of stressors for their clients and the ways in which they may manifest in a crisis. The first step in assessing for crisis occurs with the basic establishment of a therapeutic nurse-patient relationship. Understanding who your patient is, what is occurring in their life, what resources are available to them, and their individual beliefs, supports, and general demeanor can help a nurse determine if a patient is at risk for ineffective coping and possible progression to crisis.

Crisis symptoms can manifest in various ways. Nurses should carefully monitor for signs of the progression through the phases of crisis such as the following:

• Escalating anxiety
• Denial
• Confusion or disordered thinking
• Anger and hostility
• Helplessness and withdrawal
• Inefficiency
• Hopelessness and depression
• Steps toward resolution and reorganization

When a nurse identifies these signs in a patient or their family members, it is important to carefully explore the symptoms exhibited and the potential stressors. Collecting information regarding the severity of the stress response, the individual’s or family’s resources, and the crisis phase can help guide the nurse and health care team toward appropriate intervention.

Crisis Interventions

Crisis intervention is an important role for the nurse and health care team to assist patients and families toward crisis resolution. Resources are employed, and interventions are implemented to therapeutically assist the individual in whatever phase of crisis they are experiencing. Depending on the stage of the crisis, various strategies and resources are used.

The goals of crisis intervention are the following:

• Identify, assess, and intervene
• Return the individual to a prior level of functioning as quickly as possible
• Lessen negative impact on future mental health

During the crisis intervention process, new skills and coping strategies are acquired, resulting in change. A crisis state is time-limited, usually lasting several days but no longer than four to six weeks.

Various factors can influence an individual’s ability to resolve a crisis and return to equilibrium, such as realistic perception of an event, adequate situational support, and adequate coping strategies to respond to a problem. Nurses can implement strategies to reinforce these factors.

Strategies for Crisis Phase 1 and 2

Table 3.5c describes strategies and techniques for early phases of a crisis that can help guide the individual toward crisis resolution.

Table 3.5c Phase 1 & 2 Early Crisis Intervention Strategies^[5]

Strategies for Crisis Phase 3

If an individual continues to progress in severity to higher levels of crisis, the previously identified verbal and nonverbal interventions for Phase 1 and Phase 2 may be received with a variability of success. For example, for a receptive individual who is still in relative control of their emotions, the verbal and nonverbal interventions may still be well-received. However, if an individual has progressed to Phase 3 with emotional lability, the nurse must recognize this escalation and take additional measures to protect oneself. If an individual demonstrates loss of problem-solving ability or the loss of control, the nurse must take measures to ensure safety for themselves and others in all interactions with the patient. This can be accomplished by calling security or other staff to assist when engaging with the patient. It is important to always note the location of exits in the patient’s room and ensure the patient is never between the nurse and the exit. Rapid response devices may be worn, and nurses should feel comfortable using them if a situation begins to escalate.

Verbal cues can still hold significant power even in a late phase of crisis. The nurse should provide direct cues to an escalating patient such as, “Mr. Andrews, please sit down and take a few deep breaths. I understand you are angry. You need to gain control of your emotions, or I will have to call security for assistance.” This strategy is an example of limit-setting that can be helpful for de-escalating the situation and defusing tension. Setting limits is important for providing behavioral guidance to a patient who is escalating, but it is very different from making threats. Limit-setting describes the desired behavior whereas making threats is nontherapeutic. See additional examples contrasting limit-setting and making threats in the following box.^[6]

Strategies for Crisis Phase 4

A person who is experiencing an elevated phase of crisis is not likely to be in control of their emotions, cognitive processes, or behavior. It is important to give them space so they don’t feel trapped. Many times these individuals are not responsive to verbal intervention and are solely focused on their own fear, anger, frustration, or despair. Don’t try to argue or reason with them. Individuals in Phase 4 of crisis often experience physical manifestations such as rapid heart rate, rapid breathing, and pacing.

If you can’t successfully de-escalate an individual who is becoming increasingly more agitated, seek assistance. If you don’t believe there is an immediate danger, call a psychiatrist, psychiatric-mental health nurse specialist, therapist, case manager, social worker, or family physician who is familiar with the person’s history. The professional can assess the situation and provide guidance, such as scheduling an appointment or admitting the person to the hospital. If you can’t reach someone and the situation continues to escalate, consider calling your county mental health crisis unit, crisis response team, or other similar contacts. If the situation is life-threatening or if serious property damage is occurring, call 911 and ask for immediate assistance. When you call 911, tell them someone is experiencing a mental health crisis and explain the nature of the emergency, your relationship to the person in crisis, and whether there are weapons involved. Ask the 911 operator to send someone trained to work with people with mental illnesses such as a Crisis Intervention Training (CIT) officer.^[8]

A nurse who assesses a patient in this phase should observe the patient’s behaviors and take measures to ensure the patient and others remain safe. A person who is out of control may require physical or chemical restraints to be safe. Nurses must be aware of organizational policies and procedures, as well as documentation required for implementing restraints, if the patient’s or others’ safety is in jeopardy.

Crisis Resources

Depending on the type of stressors and the severity of the crisis experienced, there are a variety of resources that can be offered to patients and their loved ones. Nurses should be aware of community and organizational resources that are available in their practice settings. Support groups, hotlines, shelters, counseling services, and other community resources like the Red Cross may be helpful. Read more about potential national and local resources in the following box.

Mental Health Crisis

When an individual is diagnosed with a mental health disorder, the potential for crisis is always present. Risk of suicide is always a priority concern for people with mental health conditions in crisis. Any talk of suicide should always be taken seriously. Most people who attempt suicide have given some warning. If someone has attempted suicide before, the risk is even greater. Read more about assessing suicide risk in the “Establishing Safety” section of Chapter 1. Encouraging someone who is having suicidal thoughts to get help is a safety priority.

Common signs that a mental health crisis is developing are as follows:

• Inability to perform daily tasks like bathing, brushing teeth, brushing hair, or changing clothes
• Rapid mood swings, increased energy level, inability to stay still, pacing, suddenly depressed or withdrawn, or suddenly happy or calm after period of depression
• Increased agitation with verbal threats; violent, out-of-control behavior or destruction of property
• Abusive behavior to self and others, including substance misuse or self-harm (cutting)
• Isolation from school, work, family, or friends
• Loss of touch with reality (psychosis) – unable to recognize family or friends, confused, doesn’t understand what people are saying, hearing voices, or seeing things that aren’t there
• Paranoia

Clients with mental illness and their loved ones need information for what to do if they are experiencing a crisis. Navigating a Mental Health Crisis: A NAMI Resource Guide for Those Experiencing a Mental Health Emergency provides important, potentially life-saving information for people experiencing mental health crises and their loved ones. It outlines what can contribute to a crisis, warning signs that a crisis is emerging, strategies to help de-escalate a crisis, and available resources.